Reset

SOCIAL SECURITY NUMBER Minnesota Department of Labor and Industry Workers’ Compensation Division 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 1-800-342-5354 (DIAL-DLI)

DATE(S) OF CLAIMED INJURY

E D 0 2

DO NOT USE THIS SPACE

EMPLOYEE VS. EMPLOYER AND INSURER

Employee’s Objection To Discontinuance
or Permanent Total Disability Benefits
Please PRINT or TYPE. Enter dates in MM/DD/YYYY format.

AND of Temporary Total, Temporary Partial

Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics.

TO THE WORKERS’ COMPENSATION DIVISION, DEPARTMENT OF LABOR AND INDUSTRY 1. The Objection to Discontinuance is filed in response to: An administrative decision issued under Minn. Stat. § 176.239 by Name of Judge and filed on or A Notice of Intention to Discontinue Benefits dated issued on this discontinuance.) or Other (Check only if no administrative decision has been served

2. The employee alleges that he/she is entitled to the following additional benefits: a. b. c. Temporary Total from Temporary Partial from Permanent Total from to to to

3. Trial Data: a. b. c. d. Requested place of: Pretrial Estimated hours to present evidence: If an interpreter is requested for a hearing or conference, specify the language/dialect: If a reasonable accommodation of disability is requested for a hearing or conference, describe: Trial

WHEREFORE, the Employee objects to the discontinuance of compensation benefits and requests that this matter be set for hearing in accordance with Minn. Stat. § 176.238.
EMPLOYEE SIGNATURE ATTORNEY FOR EMPLOYEE SIGNATURE

ADDRESS

ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

TELEPHONE

ATTORNEY REGISTRATION #

TELEPHONE

MN ED02 (6/04)

(over)

STATE OF MINNESOTA COUNTY OF I, in the United States mail at NAMES AND ADDRESSES

} } }

ss.

AFFIDAVIT OF SERVICE

, being first duly sworn, state that on , Minnesota, addressed as follows:

,I

served a true and correct copy of this document, enclosed in a properly addressed envelope, by depositing the same, with postage prepaid,

Subscribed and sworn to before me this Notary Public My Commission expires INSTRUCTIONS 1. The hearing will be expedited if the Objection to Discontinuance is within 60 calendar days after a Notice of Intention to Discontinue Benefits has been filed (if no administrative decision has been issued) or within 60 days after a decision concerning the discontinuance has been issued pursuant to Minn. Stat. § 176.239. Failure to properly and fully fill out this form, with appropriate documentation, in accordance with workers’ compensation rules of practice, is not considered proper filing. The Workers’ Compensation Division may refuse to accept this form if it lacks any of the following: employee’s name, date of injury, social security number, or name of employer/insurer. The claim must be presented in terms of the Minnesota Workers’ Compensation Act. If you have more defendants or more injuries than can be listed, this form may be modified accordingly. A doctor’s report or other information supporting the claim MUST be filed with this form. A copy of this form must be served on the employer and the insurer, their attorney, potential intervenors, and the Special Compensation Fund, if applicable, by first class mail or personally. day of Signature

2.

3. 4. 5. 6.

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.